The guy who gave the heart failure talk at SHM 2009 said that hospitalists have no evidence to guide them in the inpatient management of heart failure. That was an overstatement. We have, for example, evidence about Neseritide (maybe marginally better than IV nitro but with safety concerns raised); IV inotropes (they increase mortality); what to do with patients' beta blockers when they come in with ADHF (don't hold them or reduce the dose unless they're in shock); and the use of non-invasive positive pressure ventilation. That said, it's true that the vast majority of high level clinical evidence to guide heart failure treatment is on the ambulatory side. While that evidence on long term treatments suggests things for hospitalists to do at discharge time, even the hospital performance measures based on that evidence proved to be a bust.
So, always looking to be evidence based in the management of common problems in hospitalized patients, I found this report from the ACC national meeting to be of interest. In an example of some of that comparative effectiveness research we've all been clamoring for researchers looked at several different loop diuretic regimens: high dose, low dose, continuous infusion and boluses. It turns out it doesn't really matter. All the folklore handed down about loop diuretics may be equally true and can be summarized thusly:
Lasix dose = age + BUN (Law # 7 of the House of God).
Rales heard only at peak inspiration are “20 mg Lasix rales.” (Pearl from visiting professor William J. Grace, M.D., St. Louis University Hospital, 1976).
40 mg IV Lasix “is a pretty good dose.” (One of my resident mentors in medical school).
Give the same dose IV lasix as the patient takes PO at home. (Another resident mentor).
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